Textbook outcome in patients with biliary duct injury during cholecystectomy.

BACKGROUND: Iatrogenic bile duct injury (BDI) during cholecystectomy is associated with a complex and heterogeneous management owing to the burden of morbidity until their definitive treatment. This study aimed to define the textbook outcomes (TOs) after BDI with the purpose to indicate the ideal treatment and to improve it management. METHODS: We collected data from patients with an BDI between 1990 and 2022 from 27 hospitals. TO was defined as a successful conservative treatment of the iatrogenic BDI or only minor complications after BDI or patients in whom the first repair resolves the iatrogenic BDI without complications or with minor complications. RESULTS: We included 808 patients and a total of 394 patients (46.9%) achieved TO. Overall complications in TO and non-TO groups were 11.9% and 86%, respectively (P < .001). Major complications and mortality in the non-TO group were 57.4% and 9.2%, respectively. The use of end-to-end bile duct anastomosis repair was higher in the non-TO group (23.1 vs 7.8, P < .001). Factors associated with achieving a TO were injury in a specialized center (adjusted odds ratio [aOR], 4.01; 95% CI, 2.68-5.99; P < .001), transfer for a first repair (aOR, 5.72; 95% CI, 3.51-9.34; P < .001), conservative management (aOR, 5.00; 95% CI, 1.63-15.36; P = .005), or surgical management (aOR, 2.45; 95% CI, 1.50-4.00; P < .001). CONCLUSION: TO largely depends on where the BDI is managed and the type of injury. It allows hepatobiliary centers to identify domains of improvement of perioperative management of patients with BDI.

Solid pseudopapillary neoplasms of the pancreas: Multicenter Vasepa study.

INTRODUCTION: Solid pseudopapillary tumors (SPT) of the pancreas are rare exocrine neoplasms of the pancreas. Correct preoperative diagnosis is not always feasible. The treatment of choice is surgical excision. These tumors have a good prognosis with a high disease-free survival rate. OBJECTIVE: To describe the clinicopathological and radiological characteristics as well as short- and long-term follow-up results of patients who have undergone SPT resection. METHODS: Multicenter retrospective observational study in patients with SPT who had undergone surgery from January 2000-January 2022. We have studied preoperative, intraoperative, and postoperative variables as well as the follow-up results (mean 28 months). RESULTS: 20 patients with histological diagnosis of SPT in the surgical specimen were included. 90% were women; mean age was 33.5 years (13-67); 50% were asymptomatic. CT was the most used diagnostic test (90%). The most frequent location was body-tail (60%). Preoperative biopsy was performed in 13 patients (65%), which was correct in 8 patients. Surgeries performed: 7 distal pancreatectomies, 6 pancreaticoduodenectomies, 4 central pancreatectomies, 2 enucleations, and 1 total pancreatectomy. The R0 rate was 95%. Four patients presented major postoperative complications (Clavien-Dindo > II). Mean tumor size was 81 mm. Only one patient received adjuvant chemotherapy. With a mean follow-up of 28 months, 5-year disease-free survival was 95%. CONCLUSION: SPT are large, usually located in the body-tail of the pancreas, and more frequent in women. The R0 rate obtained in our series is very high (95%). The oncological results are excellent.

Novel Benchmark Values for Open Major Anatomic Liver Resection in Non-cirrhotic Patients: A Multicentric Study of 44 International Expert Centers.

OBJECTIVE: This study aims at establishing benchmark values for best achievable outcomes following open major anatomic hepatectomy for liver tumors of all dignities. BACKGROUND: Outcomes after open major hepatectomies vary widely lacking reference values for comparisons among centers, indications, types of resections, and minimally invasive procedures. METHODS: A standard benchmark methodology was used covering consecutive patients, who underwent open major anatomic hepatectomy from 44 high-volume liver centers from 5 continents over a 5-year period (2016-2020). Benchmark cases were low-risk non-cirrhotic patients without significant comorbidities treated in high-volume centers (≥30 major liver resections/year). Benchmark values were set at the 75th percentile of median values of all centers. Minimum follow-up period was 1 year in each patient. RESULTS: Of 8044 patients, 2908 (36%) qualified as benchmark (low-risk) cases. Benchmark cutoffs for all indications include R0 resection ≥78%; liver failure (grade B/C) ≤10%; bile leak (grade B/C) ≤18%; complications ≥grade 3 and CCI ® ≤46% and ≤9 at 3 months, respectively. Benchmark values differed significantly between malignant and benign conditions so that reference values must be adjusted accordingly. Extended right hepatectomy (H1, 4-8 or H4-8) disclosed a higher cutoff for liver failure, while extended left (H1-5,8 or H2-5,8) were associated with higher cutoffs for bile leaks, but had superior oncologic outcomes, when compared to formal left hepatectomy (H1-4 or H2-4). The minimal follow-up for a conclusive outcome evaluation following open anatomic major resection must be 3 months. CONCLUSION: These new benchmark cutoffs for open major hepatectomy provide a powerful tool to convincingly evaluate other approaches including parenchymal-sparing procedures, laparoscopic/robotic approaches, and alternative treatments, such as ablation therapy, irradiation, or novel chemotherapy regimens.

Vascular injury during cholecystectomy: A multicenter critical analysis behind the drama.

BACKGROUND: The management of a vascular injury during cholecystectomy is still very complicated, especially in centers not specialized in complex hepatobiliary surgery. METHODS: This was a multi-institutional retrospective study in patients with vascular injuries during cholecystectomy from 18 centers in 4 countries. The aim of the study was to analyze the management of vascular injuries focusing on referral, time to perform the repair, and different treatments options outcomes. RESULTS: A total of 104 patients were included. Twenty-nine patients underwent vascular repair (27.9%), 13 (12.5%) liver resection, and 1 liver transplant as a first treatment. Eighty-four (80.4%) vascular and biliary injuries occurred in nonspecialized centers and 45 (53.6%) were immediately transferred. Intraoperative diagnosed injuries were rare in referred patients (18% vs 84%, P = .001). The patients managed at the hospital where the injury occurred had a higher number of reoperations (64% vs 20%, P ˂ .001). The need for vascular reconstruction was associated with higher mortality (P = .04). Two of the 4 patients transplanted died. CONCLUSION: Vascular lesions during cholecystectomy are a potentially life-threatening complication. Management of referral to specialized centers to perform multiple complex multidisciplinary procedures should be mandatory. Late vascular repair has not shown to be associated with worse results.

Machine Learning-Based Analysis in the Management of Iatrogenic Bile Duct Injury During Cholecystectomy: a Nationwide Multicenter Study.

BACKGROUND: Iatrogenic bile duct injury (IBDI) is a challenging surgical complication. IBDI management can be guided by artificial intelligence models. Our study identified the factors associated with successful initial repair of IBDI and predicted the success of definitive repair based on patient risk levels. METHODS: This is a retrospective multi-institution cohort of patients with IBDI after cholecystectomy conducted between 1990 and 2020. We implemented a decision tree analysis to determine the factors that contribute to successful initial repair and developed a risk-scoring model based on the Comprehensive Complication Index. RESULTS: We analyzed 748 patients across 22 hospitals. Our decision tree model was 82.8% accurate in predicting the success of the initial repair. Non-type E (p < 0.01), treatment in specialized centers (p < 0.01), and surgical repair (p < 0.001) were associated with better prognosis. The risk-scoring model was 82.3% (79.0-85.3%, 95% confidence interval [CI]) and 71.7% (63.8-78.7%, 95% CI) accurate in predicting success in the development and validation cohorts, respectively. Surgical repair, successful initial repair, and repair between 2 and 6 weeks were associated with better outcomes. DISCUSSION: Machine learning algorithms for IBDI are a novel tool may help to improve the decision-making process and guide management of these patients.

Reaching a consensus on the definition of "difficult" cholecystectomy among Spanish experts. A Delphi project. A qualitative study.

BACKGROUND: Being able to predict preoperatively the difficulty of a cholecystectomy can increase safety and improve results. However, there is a need to reach a consensus on the definition of a cholecystectomy as "difficult". The aim of this study is to achieve a national expert consensus on this issue. METHODS: A two-round Delphi study was performed. Based on the previous literature, history of biliary pathology, preoperative clinical, analytical, and radiological data, and intraoperative findings were selected as variables of interest and rated on a Likert scale. Inter-rater agreement was defined as "unanimous" when 100% of the participants gave an item the same rating on the Likert scale; as "consensus" when ≥80% agreed; as "majority" when the agreement was ≥70%. The delta of change between the two rounds was calculated. RESULTS: After the two rounds, the criteria that reached "consensus" were bile duct injury (96.77%), non-evident anatomy (93.55%), Mirizzi syndrome (93.55%), severe inflammation of Calot's triangle (90.32%), conversion to laparotomy (87.10%), time since last acute cholecystitis (83.87%), scleroatrophic gallbladder (80.65%) and pericholecystic abscess (80.65%). CONCLUSION: The ability to predict difficulty in cholecystectomy offers important advantages in terms of surgical safety. As a preliminary step, the items that define a surgical procedure as difficult should be established. Standardization of the criteria can provide scores to predict difficulty both preoperatively and intraoperatively, and thus allow the comparison of groups of similar difficulty.

Bacterial DNA translocation contributes to systemic inflammation and to minor changes in the clinical outcome of liver transplantation.

Bacterial (bact)DNA is an immunogenic product that frequently translocates into the blood in cirrhosis. We evaluated bactDNA clearance in patients undergoing liver transplantation (LT) and its association with inflammation and clinically relevant complications. We prospectively included patients consecutively admitted for LT in a one-year follow-up study. We evaluated bactDNA before and during the first month after LT, quantifying cytokine response at 30 days. One hundred patients were included. BactDNA was present in the blood of twenty-six patients undergoing LT. Twenty-four of these showed bactDNA in the portal vein, matching peripheral blood-identified bactDNA in 18 cases. Thirty-four patients showed bactDNA in blood during the first month after LT. Median TNF-α and IL-6 levels one month after LT were significantly increased in patients with versus without bactDNA. Serum TNF-α at baseline was an independent risk factor for bactDNA translocation during the first month after LT in the multivariate analysis (Odds ratio (OR) 1.14 [1.04 to 1.29], P = 0.015). One-year readmission was independently associated with the presence of bactDNA during the first month after LT (Hazard ratio (HR) 2.75 [1.39 to 5.45], P = 0.004). The presence of bactDNA in the blood of LT recipients was not shown to have any impact on complications such as death, graft rejection, bacterial or CMV infections. The rate of bactDNA translocation persists during the first month after LT and contributes to sustained inflammation. This is associated with an increased rate of readmissions in the one-year clinical outcome after LT.

Enseñanza de la Cirugía: nuevos tiempos, nuevos métodos / Teaching surgery: new times, new methods

Introducción La organización, seguimiento y calidad de la docencia postgrado es probablemente una asignatura pendiente en nuestro medio. Este proyecto se plantea un objetivo claro: utilizar una herramienta docente más práctica y eficaz que las disponibles hasta el momento. No solo nos planteamos evaluar al residente, sino aportar el material de estudio ya consensuado y revisado por sus responsables. Todo esto mediante un método fácil, accesible y gratuito que garantice su formación básica. Material y método Primeramente identificamos los problemas prácticos de la residencia de cirugía general en nuestro medio. Confeccionamos una encuesta y la enviamos por correo electrónico a todos los residentes a partir de segundo año de la Comunidad Autónoma del País Vasco. Con los resultados diseñamos un sistema de carpetas con Google Documents™ y lo comenzamos a aplicar en los de tercer y cuarto años. Resultados Los métodos tradicionales de la enseñanza de la Cirugía han quedado en parte obsoletos por el empuje tecnológico de las Ciencias de la Información. Las nuevas generaciones dominan de forma natural tanto la red como las aplicaciones informáticas más comunes. A nuestro alcance tenemos una serie de herramientas que por desconocimiento o falta de tiempo no utilizamos. Este trabajo pretende aportar una opción de trabajo que facilite la labor del tutor como figura docente, ya que la actividad asistencial frecuentemente no deja sitio para la interacción con el residente (AU)

Introduction The organisation, follow-up and quality of post-graduate teaching may be in need of appraisal in our area. This study sets out a clear objective: to use a more practical and effective teaching tool than we currently have available. Not only will it set out to assess the resident, but also provide material already approved and reviewed by their tutors. All this will be achieved using an easy, accessible and free method which ensures their basic training. Material and method Firstly, we identified the practical problems in the general surgery residency in our area. We prepared a questionnaire and sent it by e-mail to all second year and over residents of the Basque Country Autonomous Community. From the results obtained, we designed a file system with Google Documents™ and we started to apply it the third and fourth years. Results The teaching methods in Surgery have partly become obsolete due to the initiative of Information Sciences Technology. The new generations naturally dominate the Internet along with the more common computer applications. Within our reach we have a series of tools that, due to lack of knowledge or lack of time, we do not use. This article attempts to provide a working option that will help the job of the tutor as a teaching figure, since the health care activity often has no place for interaction with the resident (AU)

Evaluación del riesgo quirúrgico de 1.000 episodios consecutivos con el sistema POSSUM. Comparación entre cirugía gastrointestinal programada y urgente / Assessment of the surgical risk of 1, 000 consecutive episodes using the POSSUM system. Comparison between elective and emergency gastrointestinal surgery

Introducción El objetivo del presente estudio fue evaluar la capacidad predictiva del sistema POSSUM en nuestro medio y determinar su comportamiento en cirugía gastrointestinal programada y compararla con la urgente. Pacientes y método Se analizaron 1.000 episodios quirúrgicos correspondientes a 909 pacientes intervenidos con anestesia general o loco-regional, de forma programada (n=547 episodios) o urgente (n=453), que precisaron ingreso hospitalario. Resultados La morbilidad total fue 31,9% (32,9% en cirugía programada y 30,7% en cirugía urgente). La capacidad discriminativa de la escala POSSUM evaluada mediante curva ROC fue mayor para la mortalidad Portsmouth (área bajo la curva [ABC] =0,92) que para la morbilidad (ABC=0,74). La bondad de ajuste o grado de calibración entre los valores esperados usando la escala POSSUM y los observados fue reducida para la morbilidad (Hosmer-Lemeshow [H-L] =164,1; p<0,05). La escala POSSUM predijo un número considerablemente mayor de muertes a las observadas, aunque la variante Portsmouth predijo mejor la mortalidad. El grado de calibración de la morbilidad fue mejor para la cirugía gastrointestinal programada (H-L=27,7) que para la cirugía gastrointestinal urgente (H-L=177,3). Mediante análisis de regresión logística se identificó, además del riesgo estimado mediante la propia escala POSSUM, las variables complejidad quirúrgica, tipo de cirugía y edad del paciente como factores significativos predictivos de la aparición de morbilidad y mortalidad. Conclusiones En nuestro medio, el sistema POSSUM predice adecuadamente el riesgo de morbilidad de la cirugía gastrointestinal programada, y sobreestima el riesgo de morbilidad de la cirugía gastrointestinal urgente (AU)

Introduction The aim of the present study was to assess the predictive capacity of the POSSUM system in a Spanish university hospital, and to determine its behaviour in elective gastrointestinal surgery and compare it with emergency gastrointestinal surgery (operation < 24 hours).Patients and method A total of 1,000 surgical episodes corresponding to 909 patients who required hospital admission, operated on under general or loco-regional anaesthesia, either in the elective (n= 547 episodes) or the emergency setting (n= 453), were included in the study. Results The overall morbidity was 31.9% (32.8% in elective surgery; 30.7% in emergency surgery). The discriminatory capacity of the POSSUM scale, evaluated using receiver operating characteristic (ROC) curves, was higher for the Portsmouth variant of mortality (Area Under the Curve [AUC] = 0,92) than for morbidity (AUC= 0,74). The goodness of fit between the expected values using the POSSUM scale and those observed was reduced for morbidity (Hosmer-Lemeshow [H-L] = 164.1; p< 0.05). The POSSUM scale predicted a higher number of deaths than those observed, although the Portsmouth variant was better at predicting mortality. The goodness of fit for morbidity was better for elective gastrointestinal surgery (H-L= 27.7) than emergency gastrointestinal surgery (H-L= 177.3). The logistic regression analysis identified (besides the estimated risk using the POSSUM scale itself), surgical complexity, surgery type (elective, emergency), and age of patient, as significant predictive factors of morbidity and mortality. Conclusions In a Spanish university hospital, the POSSUM system adequately predicts morbidity risk in elective gastrointestinal surgery, and over-estimates morbidity risk in emergency gastrointestinal surgery (AU)

[Assessment of the surgical risk of 1,000 consecutive episodes using the POSSUM system. Comparison between elective and emergency gastrointestinal surgery]. / Evaluación del riesgo quirúrgico de 1.000 episodios consecutivos con el sistema POSSUM. Comparación entre cirugía gastrointestinal programada y urgente.

INTRODUCTION: The aim of the present study was to assess the predictive capacity of the POSSUM system in a Spanish university hospital, and to determine its behaviour in elective gastrointestinal surgery and compare it with emergency gastrointestinal surgery (operation < 24 hours). PATIENTS AND METHOD: A total of 1,000 surgical episodes corresponding to 909 patients who required hospital admission, operated on under general or loco-regional anaesthesia, either in the elective (n= 547 episodes) or the emergency setting (n= 453), were included in the study. RESULTS: The overall morbidity was 31.9% (32.8% in elective surgery; 30.7% in emergency surgery). The discriminatory capacity of the POSSUM scale, evaluated using receiver operating characteristic (ROC) curves, was higher for the Portsmouth variant of mortality (Area Under the Curve [AUC] = 0,92) than for morbidity (AUC= 0,74). The goodness of fit between the expected values using the POSSUM scale and those observed was reduced for morbidity (Hosmer-Lemeshow [H-L] = 164.1; p< 0.05). The POSSUM scale predicted a higher number of deaths than those observed, although the Portsmouth variant was better at predicting mortality. The goodness of fit for morbidity was better for elective gastrointestinal surgery (H-L= 27.7) than emergency gastrointestinal surgery (H-L= 177.3). The logistic regression analysis identified (besides the estimated risk using the POSSUM scale itself), surgical complexity, surgery type (elective, emergency), and age of patient, as significant predictive factors of morbidity and mortality. CONCLUSIONS: In a Spanish university hospital, the POSSUM system adequately predicts morbidity risk in elective gastrointestinal surgery, and over-estimates morbidity risk in emergency gastrointestinal surgery.